Incontinence: It's NOT normal, NOT acceptable, NOT a disease


Kara Schuft

Author: Kara Schuft, PT, DPT: Doctor of Physical Therapy, Business owner, and Blog Contributor. Specializing in chronic pain, pelvic health and peripartum care. Passionate about health literacy and conversation around our changing bodies throughout the lifespan. Learn more about Kara here.


What is incontinence and who does it affect?

Did you know that nearly 13 million Americans have some form of incontinence (going to the bathroom or leaking urine when you don't want to)? And that 85% of incontinence sufferers are women? Additionally, 50% of nursing home residents have incontinence. In summary, incontinence affects all ages, sexes and populations. However, just because incontinence is more common than it may seem, it doesn't mean that it's something anyone should feel they have to live with or tolerate forever. 

Is all incontinence the same?

Many people don't know that there are different types of incontinence - not all incontinence is the same. There are 2 different types of incontinence: urge incontinence, and stress incontinence. Let's parse these 2 types of incontinence out.

What is urge incontinence?

Urge incontinence is characterized by a strong desire to urinate. When your bladder is full, the tissues of the bladder stretch and this sends a signal to your brain that you need to go to the bathroom. With urge incontinence, your bladder sends a signal to your brain that you need to go to the bathroom when you don't want it to - when you are not ready to urinate or void. When these contractions happen, you can urinate large volumes. These contractions or urges to urinate can be triggered by a variety of things such as putting your key in the door when you get home, pulling your car into the garage, or the sound of running water. No matter what your trigger may be, the good news is that urge incontinence can be treated (see below for treatment information).

What is stress incontinence?

Stress incontinence is characterized by leaking urine when there is  an increase in intra-abdominal pressure. Intra-abdominal pressure increases with sneezing, coughing, laughing, and physical exertion (such as heavy lifting [carrying a heavy grocery bag, lifting your child, etc.]). When intra-abdominal pressure increases, this puts a strain on the muscles around the urethra which are responsible for holding urine in and not letting it leak. If these muscles around the urethra are weak, this extra strain does not allow these muscles to do their job of keeping urine in the bladder. Whether it's coughing, sneezing, laughing, or heavy lifting that's causing urine to leak, stress incontinence can be treated (see below for treatment information)!

What are normal bladder habits?

The bladder is made up of a unique type of muscle tissue that allows for contraction, or tightening for voiding, and expansion, or stretching for storage. When the bladder is storing fluid it can hold up to 400-600 mL. Stretching of the bladder muscle tissue is what tells your brain that you need to go to the bathroom.  You get the first signal to your brain that you need to go to the bathroom when the bladder is half full (contains approximately 200-300 mL). It is normal to void 5-7 times per day, approximately every 3-4 hours, with each void lasting approximately 8 seconds or longer (urine comes out in a stream for at least 8 seconds each time you go to the bathroom).  Proper urination relies on a coordination between the bladder muscular tissue and the pelvic floor muscles. When you empty your bladder, the muscle tissue of the bladder contracts to help push the urine out and the surrounding muscles in the pelvic floor relax to allow for the urine to leave the body.  

What are abnormal or poor bladder habits?

It is not normal to go to the bathroom at night unless you are older than 65 years of age. It is also not normal to go to the bathroom "just in case" - for example, going to the bathroom before you leave the house, even when you don't have the urge to go, just in case you have to go later. It is not normal to strain or have to void in a semi-squat position. Additionally, it is abnormal to void infrequently ( >4 hours at time) which may be caused by not drinking enough water in a day (normal water consumption for adequate hydration is 32-64 oz). Furthermore, it is not normal to practice doing a kegel when voiding. As mentioned above, the pelvic floor muscles need to relax in order to expel urine. When you perform a kegel, you are contracting the pelvic floor rather than relaxing it which is not the normal or natural coordination of these muscles working together. 

Incontinence

  • Affects 13 million Americans
  • 85% of them are women
  • Often takes 2-3 years for one to seek help
  • 50% of nursing home residents suffer from incontinence

Urge Incontinence

  • Strong desire to urinate
  • Bladder contracts when you don't want it to
  • Large amounts of urine can be lost
  • Triggers (key in the door, running water)

Treatment: pharmacology, surgery, behavioral retraining

Stress Incontinence

  • Lose urine with an increase in intra-abdominal pressure
  • Cough, sneeze, laugh, physical exertion
  • Muscles around the urethra are weak

Treatment: pharmacology, surgery, behavioral retraining

Normal bladder and bladder habits

  • The bladder holds 400-600 mL
  • 1st urge to void when it's ½ full
  • Voiding = the bladder contracts and the pelvic floor relaxes
  • Each void should be 8 seconds or longer 
  • Void 5-7 times per day
  • Void no more than every 3-4 hours
  • No voiding at night unless >65
  • No “Just-In-Case-ing” (JIC'ing)

Abnormal bladder and bladder habits

  • Going “Just in Case”
  • Voiding in a semi-squat position
  • Straining when voiding
  • Not voiding for >4/ hours at a time
  • Not drinking 32-64 oz of water per day
  • Practicing kegels when voiding

What can I do to help myself?

Drink fluids

Water is the best form of hydration for your body and for the health of your bladder. In fact, some fluids can make your incontinence worse because they irritate the bladder due to their high acidity. These bladder irritants include caffeinated beverages such as coffee or tea and carbonated beverages such as soda/soft drinks/pop. If you find water boring or are craving a warm beverage, you can try drinking decaffeinated, herbal tea or try adding a lemon to your water or even a few drops of juice. If you are a Northwest coffee devotee, try switching to decaffeinated coffee but make sure that it is Swiss Water Processed (SWP) because this will remove all of the caffeine from the coffee versus other forms of (chemical) processing that may result in only 15% removal of the caffeine. If you're voiding a lot at night, it is generally recommended that you try not to drink any fluids approximately one hour before you go to bed. Try to space your hydration out more evenly throughout the day rather than packing it all in late in the afternoon or at night time.

Change your diet

In addition to avoiding caffeinated and carbonated beverages, avoid eating large amounts of chocolate or spicy foods as they are also highly acidic and can irritate the bladder. 

Interval training/scheduled voiding

One way to help with increased frequency of urinating is to create a schedule for voiding. You can start voiding 1 time per hour or 1 time every 2 hours. If you are able to maintain this schedule and not having any accidents or leaking, you can increase the time in between voids to 15 to 30 minutes, gradually working your way up to voiding every 3-4 hours. Once you have achieved a voiding schedule of every 3-4 hours (with no voiding at night if you are under age 65) you have reached a normal voiding pattern and do not need to try to increase the time in between voiding.

Wean off pads

As you decrease your frequency of leaking and become more confident in your bladder habits, you can begin to wean off of pads. It is important to wean off of pads because they can cause skin irritation and breakdown. Also, menstrual pads are not effective for incontinence because they are not designed for the amount of fluid that may leak with urinary incontinence. Using menstrual pads may increase the likelihood that your clothes may become soiled and that you will have skin breakdown.

Pelvic floor muscle contractions

Have you ever heard of a kegel (perhaps from Sex and the City)? It is important to note that kegels are not always the answer to solving incontinence (keep reading to find out why). A kegel is a contraction or tightening of the pelvic floor muscles. The pelvic floor muscles are a layer of muscles that create the base of the bowl of the pelvis. Kegels are often described as an upward "lifting" of the pelvic floor or the base of the bowl of the pelvis. Kegels can be performed in a variety of ways depending on what you are trying to train - endurance, strength, or decreased ability to fatigue. The great thing about kegels is that they are an exercise you can perform when driving in your car, sitting on the couch and watching TV, or having coffee with a friend - if done properly, nobody will be able to tell you are doing them!

Relaxing the pelvic floor muscles can be just as effective at reducing incontinence as contracting them, depending on the underlying issue of the pelvic floor musculature. Another way to activate the pelvic floor muscles besides doing a kegel is to do some deep breathing. The diaphragm and the pelvic floor muscles work in sync, so that each time you take a deep breath in using your diaphragm, the pelvic floor muscles relax and lengthen or stretch. This can be particularly helpful if some of your incontinence is due to over-activity of the pelvic floor muscles, in which case the pelvic floor muscles are staying in a contracted, shortened position in resting and therefore the muscle fibers cannot align optimally to create a strong contraction. As such, lengthening and relaxing the pelvic floor muscles with diaphragmatic breathing can help to stretch these overly tight muscles so that they are in a more optimal resting position and can perform a strong, full contraction, helping with incontinence. 

Stress incontinence suppression

If you are having problems holding your urine when you sneeze, laugh, or cough, try performing a kegel before this activity (if you are able to predict a sneeze is on the way). You may need to complete a pelvic floor strengthening program which may include doing 30-80 repetitions of kegels per day for 8 weeks and then tapering down to 15 repetitions of kegels per day for strength maintenance.

Urge suppression

Kegels can be performed in two different ways to help with urge incontinence. One way is to train the pelvic floor muscles for endurance by performing a kegel and holding it for 10 seconds. The other way to perform a kegel for urge suppression is to train the pelvic floor for decreased ability to fatigue. To decrease the fatiguability of the pelvic floor muscles you can perform a kegel 10 times, holding each contraction for no more than 1 second, followed by a quick relaxation lasting no more than 1 second. These types of pelvic floor contractions are sometimes referred to as a "quick flick."

Another technique for reducing the urge to urinate is to distract yourself when you feel the urge to go to the bathroom. As mentioned previously, various sounds, smells, locations, or noises may trigger or intensify the sensation of the need to go to the bathroom - when this happens, try to distract your mind by thinking of something besides going to the bathroom. This distraction may include just thinking of something else, taking a few deep breaths, or listening to some music or singing a song to yourself - you can try whatever is an effective distraction technique for you! Once the urge to go to the bathroom has passed, you can walk SLOWLY to the bathroom and void if needed.

Positioning and Voiding

Positioning on the toilet is extremely important for addressing incontinence! The ideal position on the toilet is to have your feet on a 5-6 inch foot stool so that the bend of your knees is slightly above the bend of your hips with your body or trunk leaning forward slightly. You should not have to push or strain or hold your breath when voiding urine or when having a bowel movement. 

What can I do to help myself?

  1. HYDRATE
  2. Don't overload at night

Diet

  1. Avoid irritants
    1. ie: coffee, tea, carbonation, soft drinks, caffeine, chocolate, spice foods
  2. Makes urine more acidic

Interval training/Scheduled voiding

  1. Start at voiding 1x/hour or 1x/2 hours
  2. Increase by 15-30 minutes when it is easy and there are no accidents
  3. End at a voiding interval of every 3-4 hours

Wean off pads

  1. Can lead to skin irritation
  2. Menstrual pads are not appropriate for urinary incontinence

Urge Suppression

  1. Kegels: 10 second hold, 10 quick flicks
  2. Sit and do some deep breathing
  3. Wait out the wave!
  4. Distract yourself
  5. When the urge has passed, you can walk SLOWLY to the bathroom

Kegels/Pelvic Floor Muscle Contractions (no one should be able to tell!)

  1. Practice doing a Kegel before the activity with which you lose urine
  2. Contract before sneezing, laughing, coughing...
  3. Strengthening program
  4. 30-80 reps a day for 8 weeks
  5. Then maintenance at 15 reps per day